Management of patients with complications of cirrhosis.

Cirrhosis results from repeated hepatocellular injury over time, leading to portal hypertension and the development of ascites, hepatic encephalopathy, and varices. Despite improvements in medical care for patients with cirrhosis, mortality from infection, renal failure, and hepatocellular carcinoma remain high.

Hepatorenal syndrome: a comprehensive overview for the critical care nurse.

Over the past 50 years, the pathophysiology and features of the hepatorenal syndrome have been illuminated. The syndrome can be divided into 2 distinct clinical patterns: a rapidly progressive renal failure with an extremely poor prognosis (type 1) and a slow progressive renal failure that correlates with the degree of cirrhosis (type 2). Although our understanding of hepatorenal syndrome continues to grow, our current methods of treating this condition remain limited in their effectiveness. The only definitive therapy is liver transplantation. This is a review of the definition, pathophysiology, and current recommendations for management of hepatorenal syndrome with the critical care nurse in mind.

Intraosseous route as alternative access for infusion therapy.

The safe and effective use of intraosseous (IO) access is evolving from its historical use only for emergent access for pediatric patients to use in adult trauma patients and, more recently, for adult inpatients. Current data and research support the use of IO route for infusion in patients of any age as a safe, rapid, and equally effective alternative to intravenous access. The article provides an overview of IO access indications, care, and management; describes therapies administered via IO access; and discusses the expanding use of IO access into areas within hospitals during nonemergent clinical situations.

Hepatorenal syndrome.

The exact physiologic mechanism of the hepatorenal syndrome remains unclear; however, it always develops in the presence of liver failure. A number of theories have been postulated to explain the syndrome, which are discussed in this review. None of the proposed theories is able to explain the syndrome completely, and continued research is necessary. Management of hepatorenal syndrome is directed at supporting the patient and maintaining/restoring hepatic function to prevent further renal damage. Liver transplantation has been considered an effective method of treatment for this patient population. Nursing care is supportive and focuses on maintaining the patients' internal environment and psychologic well-being.

Case study: end stage liver failure patient managed with CAVH pretransplant.

The patient met 4 of the 5 expected outcomes. Effective therapy with CAVH was maintained in the ICU setting and in the operating room. The catheters functioned throughout the entire treatment without signs or symptoms of infection, bleeding, or thrombosis. She received hyperalimentation, filtration replacement fluid, and adequate fluid boluses to maintain volume status, nutritional requirements and vital signs. Cardiac vasopressor medications were required for a short period. The one problem that did occur was related to the anticoagulation therapy. The PTT was checked every 4 hours and the heparin drip was titrated to keep the PTT at 50 to 60 seconds. At one point, the PTT was 92 seconds but immediate measures were undertaken to reverse the condition. In the situation where a patient has an underlying coagulopathy and a potential source of bleeding, the nursing recommendation is that hourly bedside ACTs with every 4 hour PTTs should be performed as a routine part of the care. CRRT has been used successfully in critically ill unstable patients with multiorgan involvement. These therapies provide an avenue for collaboration between nursing professionals in nephrology and critical care. The focus of CRRT can now progress from the technical aspects of the procedures to patient centered nursing issues.

Continuous arteriovenous hemofiltration in the patient with hepatorenal syndrome. A case study.

CAVH has gained increasing medical acceptance, as favorable outcomes in the critically ill have proven its worth. Unfortunately, CAVH is often used as a "last ditch" effort for the patient with multisystem organ failure and septicemia. Performing the procedure in such a setting sometimes seems little more than an exercise in futility. However, as more patients such as the patient described in this case study are shown to benefit from CAVH, the nursing role needs to be examined both in performing the procedure and in caring for the critically ill patients. The nursing literature has kept abreast of the procedural aspects of CAVH. Now, critical care nurses must move on to the patient-oriented approach, share case studies, and work together to formulate nursing diagnoses, develop specialized care plans, and identify areas for nursing research.